Hemodynamic Effects of Nitroglycerin Ointment in Emergency Department Patients

Abstract

Background Nitroglycerin ointment is commonly used in the treatment of emergency department (ED) patients with suspected acute heart failure (AHF) or suspected acute coronary syndrome (ACS), but its hemodynamic effects in this population are not well described. Objectives Our objective was to assess effect of nitroglycerin ointment on mean arterial pressure (MAP) and systemic vascular resistance (SVR) in ED patients receiving nitroglycerin. We hypothesized that nitroglycerin ointment would result in a reduction of MAP and SVR in the acute treatment of patients. Methods We conducted a prospective, observational pilot study in a convenience sample of adult patients from a single ED who were treated with nitroglycerin ointment. Impedance cardiography was used to measure MAP, SVR, cardiac output (CO), stroke volume (SV), and thoracic fluid content (TFC) at baseline and at 30, 60, and 120 minutes following application of nitroglycerin ointment. Mixed effects regression models with random slope and random intercept were used to analyze changes in hemodynamic parameters from baseline to 30, 60, and 120 minutes after adjusting for age, sex, and final ED diagnosis of AHF. Results Sixty-four subjects with mean age 55 years (IQR 48-67) were enrolled; 59% were male. In the adjusted analysis, MAP and TFC decreased following application of nitroglycerin ointment (p=0.001 and p=0.043, respectively). CI, CO, SVR, and SV showed no change (p=0.113, p=0.085, p=0.570, and p=0.076, respectively) over time. Conclusions Among ED patients who are treated with nitroglycerin ointment, MAP and TFC decrease over time. However, other hemodynamic parameters do not change following application of nitroglycerin ointment in these patients.

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“…Nitroglycerin is FDA-approved for the treatment of angina, but also used frequently off-label for acute coronary syndrome or decompensated heart failure. 107 It functions by converting to nitric oxide in the body, which activates guanylyl cyclase and ultimately leads to relaxation of smooth muscle within blood vessels. 108 Topical 2% nitroglycerin paste has also been used to prevent tissue ischemia (eg, mastectomy skin flap necrosis).…”

Value of nitroglycerin test in the diagnosis of heart failure in emergency department patients with undifferentiated dyspnea

“…Preload dependence of CO is less detectable in the failing heart with regard to the flat cardiac function curve 9‐11 . Postural maneuvers that change cardiac venous return have been proposed as a useful means for the diagnosis of HF in dyspneic patients, but this has rarely been described with pharmacological interventions 12‐14 . The aim of our study was to evaluate the utility of sublingual nitroglycerin administration (NTG test) and its effects on non‐invasive cardiac output measurement in the diagnosis of acute HF in ED patients presenting with acute dyspnea.…”